module 1 - the foundation: integrating tobacco use interventions into chemical dependence services
TRANSCRIPT
Module 1 - The Foundation:
Integrating Tobacco Use Interventions into Chemical Dependence Services
2
Welcome
Add Trainer Names
3
This training was developed by the Professional Development Program, under a contract with the NYS Department of Health, Tobacco Control Program.
PDP developed five classroom-based curricula and seven online modules, which are available at www.tobaccorecovery.org
4
Housekeeping
Hours of Training
Breaks and Restrooms
Tobacco Use Policy
Cell Phones
Active Participation
Complete Training Evaluation
5
Introductions
6 PM 8
Training Modules
Module 1 - The Foundation
Module 2 - Assessment, Diagnosis, Pharmacotherapy
Module 3 - Behavioral Interventions
Module 4 - Treatment Planning
Module 5 - Co-occurring Disorders
E-Learning - All Modules (www.tobaccorecovery.org)
7 PM 9
Module 1 Agenda
Introductions
Attitudes and Beliefs Activity
A Brief History
Rationale
Tobacco Dependence
NYS OASAS Regulation Part 856
8 PM 9
Module 1 Objectives
Please refer to the list of objectives in your manual.
9 PM 11
Unit 1
Setting the Stage
10 PM 12
Attitudes and Beliefs
The purpose of this activity is to help you explore your attitudes and beliefs about:
Tobacco use
Integrating tobacco interventions into chemical dependence services
Tobacco use, dependence, and recovery
11 PM 12
Attitudes and Beliefs, cont’d
Debrief
and
Process
12 PM 13
Timeline
• 1798 – 1970s: Recognition of Tobacco Dependence - Lost and Found
• 1980s - 1990s: Emerging Awareness
• 2003 - 2008: A New Century
RECOGNITION OF TOBACCO DEPENDENCELost and Found
1870s late 1800s,early 1900s
1930s 1960s-1970s
13 PM 13
1798
1798: Benjamin Rush, a physician and signer of the Declaration of Independence, identifies tobacco use as a harmful substance and observes that use supports excess alcohol consumption.
RECOGNITION OF TOBACCO DEPENDENCE
1870s late 1800s,early 1900s
1930s 1960s-1970s
14 PM 13
1798
1870s: Tobacco is identified as both a harmful addictive substance and as contributing factor in relapse from alcoholism and drug dependence.
RECOGNITION OF TOBACCO DEPENDENCE
1798 late 1800s,early 1900s
1930s 1960s-1970s
15 PM 13
1870s
Late 1800s and early 1900s: Tobacco dependence is routinely treated along with alcoholism and other drug dependence in inebriate clinics and asylums.
RECOGNITION OF TOBACCO DEPENDENCE
1870s late 1800s,early 1900s
1930s 1960s-1970s
16 PM 13
1798
RECOGNITION OF TOBACCO DEPENDENCE
1870s late 1800s,early 1900s
1930s 1960s-1970s
1930s - Oxford Group principles used to help support early recovery efforts; Oxford Group frowns on tobacco use.
1935: Beginning of Alcoholics Anonymous. Alcoholism counseling begins to evolve. Tobacco use becomes embedded in recovery practices and the recognition as a serious addiction and recovery issue is lost for many years.
17 PM 13
1798
RECOGNITION OF TOBACCO DEPENDENCE
1870s late 1800s,early 1900s
1930s 1960-1970s
1964: Surgeon General Report on Smoking and Health indentifies the adverse health effects of tobacco use.
18 PM 13
1960s: Alcoholism counseling continues to evolve. 1970s: Many former drug users become drug abuse counselors. Most counselors in both groups use tobacco.
EMERGING AWARENESS
1985 1992 1996
19 PM 14
EMERGING AWARENESS
1985 1992 1996
1985: Geraldine Delaney, founder of Little Hill-Alina Lodge in New Jersey, makes this the first tobacco-free chemical dependence treatment program.
20 PM 14
EMERGING AWARENESS
1985 1992 1996
1992: John Slade, M.D. begins the Addressing Tobacco in the Treatment of Other Addictions Project at the University of Medicine and Dentistry of New Jersey (UMDNJ)
21 PM 14
EMERGING AWARENESS
1985 1992 1996 -1997
1996: Van Dyke and Norris Addiction Treatment Centers (ATC) become the first tobacco-free chemical dependence inpatient treatment programs in New York State. Stutzman ATC follows in 1997.
22 PM 14
A NEW CENTURY
2003 2004 2005 2006 2007 2008
23 PM 15
2009
A NEW CENTURY
2003: Passage of NYS Clean Indoor Air Act, which exempts substance abuse and mental health treatment programs.
2003: American Cancer Society and ASAP of NYS create a mission statement to promote tobacco-free chemical dependence programs. OASAS task force convenes to discuss tobacco regulations and resources.
2003: NYS Partnership for the Treatment and Prevention of Tobacco Dependence convenes.
2003 2004 2005 2006 2007 2008
24 PM 15
2009
A NEW CENTURY
2004: Founding of Tobacco Recovery
Coalition of the Capital District, Albany, NY.
2004: OASAS Commissioner William GormanPolicy Statement that stated:
Prevention and treatment providers should
address all addictions including nicotine.
2003 2004 2005 2006 2007 2008
25 PM 15
2009
A NEW CENTURY
2005: All 13 OASAS-operated Addiction Treatment Centers (ATCs) in transition to be tobacco-free programs.
August 2005: OASAS Medical Director letter to all OASAS certified providers: “Addiction providers are best positioned to help patients become tobacco free to increase the quality of their lives in recovery.”
2005: Some NYS chemical dependence providers begin implementing similar policies, becoming tobacco-free agencies
2003 2004 2005 2006 2007 2008
26 PM 16
2009
A NEW CENTURY
May 2006: ASAP opens NYS Tobacco Dependence Resource Center.
November 2006: ASAP launches www.tobaccodependence.org.
December 2006: OASAS releases Local Services Bulletin No. 2006 – 10: Tobacco Dependence Practice Guidelines.
2003 2004 2005 2006 2007 2008
27 PM 16
2009
A NEW CENTURY
July 2007: OASAS Commissioner, Karen Carpenter-Palumbo - Announcement of Regulation Part 856 Tobacco-Free Services, to be effective by July 24, 2008.
ASAP Questions and Answers about Tobacco-Free Chemical Dependence Services teleconference series begins.
August 2007: NY Tobacco Control Program issues RFP to provide statewide training and technical assistance to integrate tobacco interventions into services.
September 2007: TCP starts providing $4M in Over-the-Counter Nicotine Replacement Therapy (OTC NRT) products to Patients and Staff of OASAS programs.
2003 2004 2005 2006 2007 2008
28 PM 16
2009
A NEW CENTURY
January 2008: TCP awards training and technical assistance contract to Professional Development Program, University at Albany.
March - July 2008: PDP begins training and technical assistance, launches www.tobaccorecovery.org website, selects Regional Training Centers, designs Modules 1 and 2, and begins statewide training.
July 24, 2008: OASAS Regulation Part 856 Tobacco-Free Services goes into effect.
2003 2004 2005 2006 2007 2008
29 PM 16
2009
October - December 2008: PDP launches Module 3 and Online Modules 1 and 2.
A NEW CENTURY
January – December 2009: PDP launches Modules 4 – 5, Online Modules 3 – 7, and completes statewide classroom training.
2009: Family Smoking Prevention and Tobacco Control Act enacted. The FDA is finally given the legal authority to regulate tobacco, nicotine levels, and tobacco additives, excluding menthol.
States of Washington and Texas: decide to implement tobacco-free addiction treatment services.
2003 2004 2005 2006 2007 2008
30 PM 16
2009
31 PM 17
Rationale
32 PM 17
Mission and Purpose
Treating tobacco dependence is consistent with the mission and purpose of chemical dependence services
33 PM 17
Mission Statement Example
“We provide quality, cost-effective care to those suffering from alcoholism and chemical dependency and to the many whose lives are affected by the diseases of
addiction.”
34 PM 17
Mission Statement Example 2
“Our mission is to provide a quality continuum of comprehensive treatment and related services, in a caring atmosphere and at a reasonable price, for all people
experiencing problems with alcohol or other drug use.”
35 PM 17
Skills and Knowledge
Treating tobacco dependence requires the same skills and knowledge that
addiction professionals already have to treat chemical dependence
36 PM 18
Tobacco’s Relationship to Alcohol and Other Drugs
Prevalence of Tobacco Use (National Data)
General Population 19.8%
Addiction Treatment 60 – 95%
Serious Mental Illness 75 – 80%
HIV and AIDS 50 – 70%
37 PM 18 -19
Tobacco Use 7 Days Prior To Admission in 2006
Level of Care % Using % Males % Females
Intensive Residential 76 % 74 % 82%
Community Residential 73% 71% 80%
Supportive Living 81% 79% 84%
Inpatient Rehabilitation 80% 79% 82%
Outpatient Clinic 63% 63% 65%
Outpatient Rehab 77% 76% 79%
Methadone Clinic 83% 82% 84%
Data: 2006, OASAS Certified Programs
38 PM 20
39 PM 20
40 PM 20
41 PM 20
Tobacco Industry Practices
Knowingly sells a product that when used as intended causes serious disease and death
Targets youth and denies doing so
Lots of money and no morals
Continues to lobby against further tobacco regulation
Uses massive advertising campaigns, plus insidious and deceptive marketing
42 PM 21
Toll of Tobacco UseGeneral Population - Annually
Deaths
over 438,000
Health care and productivity cost
$194.3 billion
43 PM 21
Toll of Tobacco Use
Tobacco-Related Deaths
are greater than
Alcohol or Drug-Related Deaths
among people treated for chemical dependence
44 PM 21
Toll of Tobacco Use
Bill W.
Dr. Bob
Marty Mann
45 PM 22
Toll of Tobacco Use
For every person who dies from their tobacco use, there are twenty people living with serious health problems caused by their tobacco use.
46 PM 22 -23
Toll of Tobacco Use
Tobacco-Related Health Consequences:
Commonly known
Less commonly known
47 PM 24- 25
Integrated Tobacco Dependence Treatment
Efficacy
Improved Outcomes
Unit Two
Tobacco Dependence
49 PM 28
Tobacco Dependence
Why do people use tobacco?
50 PM 28
Tobacco Dependence (cont’d)
Nicotine Dependence
vs.
Tobacco Dependence
DSM III / III-R used the term “tobacco dependence.”
Why did this change to “nicotine dependence” in the DSM-IV / DSM IV-TR?
51 PM 29
Nicotine dependence compared to cocaine and amphetamine dependence
nicotine
ACh
amphetamine
cocaine
DA
52 PM 30
Theories for Tobacco Use Prevalance
Shared Characteristics
Reinforcing Effects
Shared Brain Pathways
Modulating Effects
53 PM 31
DSM-IV-TR Criteria
Nicotine dependence criteria is not unique or different
DSM-IV-TR substance dependence criteria is used for diagnosing nicotine
dependence (a.k.a. tobacco dependence)
54 PM 32
DSM-IV-TR Criteria, cont’d
Nicotine Withdrawal
Daily use for several weeks
Cessation is followed within 24 hours by four or more physical or behavioral signs.
Symptoms causes significant distress and impairment and are not due to medical condition or other mental disorder
55 PM 33 - 34
Tobacco Dependence Treatment
Management of withdrawal is critical to successful recovery
Strong evidence of medication effectiveness
Medication effective for many populations
Insufficient evidence of effectiveness only with a few populations
56 PM 35 - 36
Tobacco Dependence Treatment (cont’d)
First-Line medications
Nicotine Replacement Therapy (NRT)
Non-nicotine medications
Combination of medications is best
Other medication levels may be affected after stopping tobacco use
Few medical contraindications
57 PM 37
Tobacco Dependence Treatment (cont’d)
Supportive Counseling
The combination of counseling and medication is more effective than either alone
Motivational Interviewing, Cognitive Behavioral Therapy, Skills Training, and Relapse
Prevention Therapy are all effective
58 PM 37
Summary - Nicotine Replacement Therapy
Nicotine medications have wide margin of safety
Dose should be at least equivalent to tobacco use
Combining tobacco medications is more effective
Patients with other chemical dependencies may require higher dosage and longer term NRT
Under-dosing may not manage withdrawal symptoms and often results in relapse
59 PM 38
Comparison of Nicotine Delivery
Diagram shows rise in nicotine levels in plasma after smoking a cigarette and after using different nicotine replacement therapy products (Adapted from Royal College of Physicians Website, per MAH Russell,1987 Nicotine intake and its regulation by smokers)
60 PM 39
The Cigarette:A Perfect Drug Delivery Device
Cigarettes - highly engineered nicotine delivery device
1 cigarette can peak the nicotine blood level 5-7x higher than the effect of a 21mg
nicotine patch
300 hits per 1 ½ pack of cigarettes
Exact Titration: frequency of use, intensity, and ability to fine tune delivery of
nicotine
61 PM 39
The Cigarette:A Perfect Drug Delivery Device (cont’d)
Allows exact dosing by user
Severely addicted smokers and those with limited income often re-light
Menthol cigarettes – allows deeper inhalation using less cigarettes to achieve higher nicotine levels
62 PM 40
How Tobacco Dependence Differs from AOD Dependence
Tobacco use does not cause intoxication
Tobacco use generally does not cause adverse behavioral outcomes
Tobacco use does not produce intense euphoria
Tobacco use may minor perceived improvements in cognitive functioning and mood
63 PM 40
How Tobacco Dependence is Similar to AOD Dependence
Affects release of dopamine and other neurotransmitters in the brain
Continued use despite serious harmful effects
Withdrawal syndrome
Rapid rates of relapse after attempts to stop
Nicotine self-administration in animal studies
64 PM 41
Reframing Language
Public Health Terminology
smoking
smoker
quit date
cessation
Recovery Terminology
65 PM 42 - 43
Challenges in Treating Tobacco Dependence
Nicotine has strong negative and positive reinforcement
Nicotine has some perceived beneficial effects
Smoking tobacco provides most intense reward effects
Nicotine is not intoxicating
Nicotine withdrawal
66 PM 45
Unit Three
OASAS Regulation Part 856
67 PM 45
What is the OASAS regulation?
What is expected of:
Patients
Staff and Volunteers
Program Administrators
Part 856 Tobacco-Free Services
68 PM 46 -47
OASAS Regulation effective July 24, 2008
Requires all OASAS certified and funded programs to “determine and establish written policies, procedures and methods governing the provision of a tobacco-free environment.”
- Section 856.5 (a)
Part 856 Tobacco-Free Services (cont’d)
69 PM 48
Tobacco-Free: No use of tobacco products in a program’s facilities, grounds or vehicles owned by or under the control of the program
Facility: The space used by the program’s patients, staff, volunteers, and visitors
Limited to space “under the direct control” of the program
- Section 856.4
Tobacco-Free Environment
70 PM 49
Define the facilities, vehicles and grounds.
Prohibit patients and visitors from bringing tobacco products and paraphernalia to the program.
Notify patients, staff, volunteers and visitors of the policy in writing.
Prohibit staff from using tobacco products while at work, during work hours.
Minimum Policy Requirements
71 PM 49
Establish tobacco-free policy for staff while on the work site.
Establish treatment modalities for patients who use tobacco.
Describe tobacco training available to all staff.
Describe tobacco prevention and education programs available to patients, staff, volunteers, and others.
Minimum Policy Requirements (cont’d)
72 PM 49
Establish procedures to address patient tobacco relapse.
“… every effort shall be made to provide appropriate treatment services…”
Establish procedures to address staff tobacco
“relapse consistent with the employment procedure…”
- Section 856.5
Minimum Policy Requirements (cont’d)
73 PM 50
Patients, staff, volunteers, and visitors may not use tobacco on program’s buildings, grounds,
and vehicles.
Patients, family members, and other visitors may not bring tobacco or paraphernalia to the
program.
Staff may not use tobacco products at work, during work hours.
Implications of the Regulation
74 PM 50
Write a tobacco-free environment policy.
Post notices and provide policy to all patients, staff, volunteers, and visitors.
Identify tobacco prevention and education programs available to patients, staff, volunteers, and visitors.
Establish treatment modalities for patients who use tobacco.
Program Administrator Responsibilities
75 PM 50
Identify tobacco use and dependence training available for staff and volunteers.
Establish procedures for patient and staff policy violations.
Manage organization’s change process.
Program Administrator Responsibilities
76 PM 51
Regulation 856 – True or False?
Patients, family members, or other visitors may not bring tobacco or tobacco paraphernalia to the program or service.
77 PM 51
Regulation 856 – True or False?
OASAS-funded Permanent Supportive Housing and Vocational Rehabilitation programs are exempt from the regulation.
78 PM 51
Regulation 856 – True or False?
Staff may use tobacco during work hours, while on break, and off premises.
79 PM 51
Regulation 856 – True or False?
For residential treatment programs, patients who relapse on tobacco must be administratively discharged.
80 PM 51
Regulation 856 – True or False?
For outpatient treatment programs, all patients must stop using tobacco for the duration of their treatment.
81 PM 53-54
Resources
The Tobacco Recovery Resource Exchange http://www.tobaccorecovery.org
E-Learning and Online Resources
OASAS http://www.oasas.state.ny.us/tobacco/index.cfm
Email: [email protected]
82
Workshop Evaluation Formand
Post Test